PERSONAL INJURY SETTLEMENT AGREEMENT

AND MUTUAL RELEASE

(Connecticut)

TABLE OF CONTENTS

1. Document Header.....................................................2
2. Definitions.........................................................3
3. Operative Provisions................................................5
4. Representations & Warranties........................................9
5. Covenants & Restrictions...........................................11
6. Default & Remedies.................................................13
7. Risk Allocation....................................................15
8. Dispute Resolution.................................................17
9. General Provisions.................................................18
10. Execution Block....................................................21

[// GUIDANCE: Delete the Table of Contents for shorter agreements. Update page numbers after finalizing.]

1. DOCUMENT HEADER

1.1 Parties
(a) Claimant: [CLAIMANT LEGAL NAME], [status; e.g., an individual], with an address at [ADDRESS] (“Claimant”).
(b) Respondent: [RESPONDENT LEGAL NAME], [entity type & jurisdiction of formation], with an address at [ADDRESS] (“Respondent”).
(c) Each a “Party” and together the “Parties.”

1.2 Effective Date
This Personal Injury Settlement Agreement and Mutual Release (“Agreement”) is effective as of [EFFECTIVE DATE] (the “Effective Date”).

1.3 Governing Law and Jurisdiction
This Agreement is governed by and construed in accordance with the tort and contract laws of the State of Connecticut, without regard to conflict-of-law principles. The state courts located in [COUNTY], Connecticut shall have exclusive jurisdiction.

1.4 Recitals
WHEREAS, Claimant alleges that on or about [DATE OF INCIDENT] Claimant sustained personal injuries arising out of [BRIEF DESCRIPTION OF INCIDENT] (the “Incident”);
WHEREAS, Claimant asserts claims for damages against Respondent (collectively, the “Claims”);
WHEREAS, Respondent denies liability but desires to resolve the Claims;
WHEREAS, the Parties wish to compromise and settle fully and finally any and all disputes arising from or related to the Incident;
NOW, THEREFORE, in consideration of the mutual covenants, promises, and payments set forth below, and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the Parties agree as follows:

2. DEFINITIONS

For purposes of this Agreement, capitalized terms have the meanings set forth below. Defined terms used in the singular include the plural and vice versa.

“Annuity Issuer” means the qualified assignment company or insurance company issuing any Structured Settlement Annuity pursuant to Section 3.2.

“Confidential Information” has the meaning assigned in Section 5.2.

“Court Approval” means written approval or an order from the appropriate Connecticut Superior Court or Probate Court, as required by Connecticut law, approving this Agreement when the Claimant is a minor or otherwise lacks legal capacity.

“Settlement Amount” means the total consideration to be paid by or on behalf of Respondent, as set forth in Sections 3.1 and 3.2, inclusive of attorneys’ fees, costs, interest, liens, and any other amounts.

“Structured Settlement Annuity” means the annuity contract purchased in accordance with Conn. Gen. Stat. §§ 52-225g—52-225l, or any successor statute, to fund the Periodic Payments described in Section 3.2.

“Third-Party Released Persons” has the meaning assigned in Section 7.1(b).

[// GUIDANCE: Add additional defined terms as needed for complex fact patterns.]

3. OPERATIVE PROVISIONS

3.1 Lump-Sum Payment
(a) Respondent shall pay Claimant a one-time lump-sum of $[LUMP SUM AMOUNT] within [NUMBER] business days after (i) execution of this Agreement by all Parties, (ii) delivery of duly executed W-9 forms, and (iii) receipt of any required Court Approval.
(b) Payment shall be made by [wire transfer/check] to a trust account designated by Claimant’s counsel.

3.2 Structured Settlement (if applicable)
(a) In addition to or in lieu of the lump-sum payment, the Parties agree to fund periodic payments (“Periodic Payments”) as follows:

(b) Respondent shall, at its sole cost, procure a Structured Settlement Annuity from [ANNUITY ISSUER] providing the Periodic Payments described above.
(c) Claimant acknowledges that the Annuity Issuer, and not Respondent, is solely responsible for the Periodic Payments once the annuity is purchased.
(d) Claimant shall not assign, transfer, or encumber the Periodic Payments except in compliance with Conn. Gen. Stat. §§ 52-225g et seq.
(e) The Parties warrant that any structured settlement complies with present IRC §§ 104(a)(2) and 130.

[// GUIDANCE: Delete Section 3.2 if the settlement is entirely lump-sum.]

3.3 Liens, Subrogation, and Medicare
(a) Claimant is solely responsible for satisfaction of all medical liens, subrogated interests, and conditional Medicare payments.
(b) Claimant represents that no Medicare conditional payment remains unresolved OR that conditional payments will be resolved pursuant to 42 U.S.C. § 1395y(b)(2).
(c) Respondent may withhold from the Settlement Amount any sum necessary to protect against double payment in the event of an unpaid lien upon reasonable written evidence of such lien.

3.4 Conditions Precedent
(a) Execution of this Agreement by all Parties;
(b) Receipt of Court Approval where required under Section 3.5; and
(c) Delivery of completed Form 1099 and Form W-9 (if applicable).

3.5 Minor or Incapacitated Claimant
If Claimant is a minor or otherwise lacks legal capacity:
(a) The Parties shall promptly submit this Agreement for Court Approval.
(b) All funds shall be paid to the duly appointed guardian or deposited into a restricted account as ordered by the court.
(c) Absent Court Approval, this Agreement is voidable at the election of Respondent.

4. REPRESENTATIONS & WARRANTIES

4.1 Mutual Representations
Each Party represents and warrants that:
(a) It has full legal right, power, and authority to execute, deliver, and perform this Agreement;
(b) The execution and performance of this Agreement do not violate any other agreement or court order binding on the Party;
(c) No assignment or conveyance of the Claims or defenses has been made that would conflict with this Agreement; and
(d) It enters this Agreement voluntarily, upon advice of counsel, and not in reliance on any representation not expressly set forth herein.

4.2 Respondent Additional Representations
Respondent represents and warrants that:
(a) It has obtained all internal approvals necessary to enter into this Agreement;
(b) The individual executing this Agreement on Respondent’s behalf is duly authorized to bind Respondent.

4.3 Survival
All representations and warranties survive the Effective Date and remain in effect until fully performed or extinguished by operation of law.

5. COVENANTS & RESTRICTIONS

5.1 No Further Claims
Claimant covenants not to commence or prosecute any civil, administrative, or other proceeding against any Released Person concerning the Incident except to enforce this Agreement.

5.2 Confidentiality
(a) Except as required by law, the Parties shall keep the terms of this Agreement confidential.
(b) Permitted disclosures include: immediate family, tax/legal advisers, insurers, and any court approving the settlement.

[// GUIDANCE: Consider adding a liquidated-damages clause for breach of confidentiality, subject to enforceability under CT law.]

5.3 Non-Disparagement
The Parties agree not to make any statement intended to disparage the reputation of the other Party regarding the Incident.

5.4 Required Filings
Each Party shall cooperate in filing any documents required to effectuate the Structured Settlement Annuity or Court Approval.

6. DEFAULT & REMEDIES

6.1 Events of Default
(a) Failure of Respondent to make the lump-sum payment within the time specified;
(b) Failure to fund the Structured Settlement Annuity;
(c) Breach of Section 5 (Covenants & Restrictions).

6.2 Notice and Cure
The non-defaulting Party shall give written notice specifying the default. The defaulting Party has ten (10) business days to cure monetary defaults and thirty (30) calendar days to cure non-monetary defaults.

6.3 Remedies
(a) If Respondent fails to pay, Claimant may file an action for breach of contract in Connecticut state court for the unpaid balance plus interest at [___]% per annum.
(b) If Claimant breaches Section 5, Respondent may seek monetary damages and injunctive relief preserving confidentiality.

6.4 Attorneys’ Fees
The prevailing Party in any action to enforce this Agreement is entitled to reasonable attorneys’ fees, costs, and expenses.

7. RISK ALLOCATION

7.1 Mutual Release and Indemnification
(a) Upon receipt of the Settlement Amount, Claimant irrevocably and unconditionally releases and forever discharges Respondent and its predecessors, successors, parents, subsidiaries, affiliates, insurers, reinsurers, officers, directors, employees, agents, and assigns (collectively, “Released Persons”) from all Claims, whether known or unknown, arising from or relating to the Incident and any damages allegedly resulting therefrom.
(b) Respondent releases Claimant and Claimant’s heirs, administrators, representatives, and assigns (collectively, “Third-Party Released Persons”) from any claim for contribution or indemnity relating to the Claims.
(c) Each Party shall indemnify, defend, and hold harmless the other from any claim or lien asserted by any third party arising out of the indemnifying Party’s failure to satisfy its obligations under this Agreement.

7.2 Limitation of Liability
Respondent’s total liability arising from the Incident is expressly capped at the Settlement Amount.

7.3 No Admission of Liability
This Agreement constitutes a compromise settlement. Neither execution nor performance shall be deemed an admission of liability or fault.

7.4 Force Majeure
No Party is liable for delay or failure to perform due to events beyond its reasonable control, including natural disasters, acts of God, war, terrorism, or governmental action, provided the affected Party gives prompt written notice and resumes performance as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law
Connecticut law governs all disputes.

8.2 Forum Selection
Exclusive jurisdiction resides with the state courts in [COUNTY], Connecticut.

8.3 Arbitration; Jury Waiver
The Parties expressly decline arbitration and do not waive any right to a jury trial unless mutually agreed in a future written instrument.

9. GENERAL PROVISIONS

9.1 Entire Agreement
This Agreement constitutes the entire understanding of the Parties concerning the subject matter and supersedes all prior discussions or writings.

9.2 Amendment
No amendment is effective unless in writing and signed by both Parties.

9.3 Waiver
Failure to enforce any provision is not a waiver of future enforcement.

9.4 Assignment
Neither Party may assign or delegate its rights or obligations without the prior written consent of the other, except that Respondent may assign its payment obligations to the Annuity Issuer.

9.5 Severability
If any provision is held invalid, the remaining provisions remain enforceable, and the invalid provision is reformed to the minimum extent necessary to comply with applicable law.

9.6 Successors and Assigns
This Agreement binds and benefits the Parties and their respective successors and permitted assigns.

9.7 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each of which is deemed an original, and all of which constitute one instrument. Signatures transmitted electronically (e.g., PDF or DocuSign) are deemed originals.

9.8 Headings
Headings are for convenience only and do not affect the interpretation of this Agreement.

10. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the Effective Date.

CLAIMANT

[CLAIMANT NAME]
Signature: ____
Printed Name: ____
Date: ________

[// GUIDANCE: Include the following if Claimant is a minor:]
Guardian/Parent: ____
Title/Relationship: ________

RESPONDENT

[RESPONDENT LEGAL NAME]
By: _______
Name: ______
Title: _____
Date: _______

[// GUIDANCE: Notarization is generally not required for Connecticut settlement agreements, but obtain a jurat if local court rules or the overseeing judge requests it.]

[// GUIDANCE:
1. Replace all bracketed placeholders with deal-specific information.
2. Ensure compliance with any Medicare Set-Aside requirements if settlement exceeds CMS thresholds.
3. Review Conn. Gen. Stat. § 52-225c regarding collateral source reductions where applicable.
4. For minors, confirm venue (typically Probate Court) and threshold amounts requiring approval per current Connecticut Practice Book § 6-10A or successor rules.
5. Confirm that structured settlements satisfy all IRS “qualified assignment” requirements to preserve tax-free status.
]